What Chances For Change Do I Have?

Q: I did not switch my insurance by the Dec. 7 deadline. My insurance rolled over so my plan will stay the same in 2014. Now I am not so sure that was smart. What chances for change do I have?

A: There are a number of Special Enrollment Periods (SEPs) that are available to all individuals with regard to Medicare Part D coverage. The SEPs stay the same year to year, but we cannot always use them. In 2014 the Five-Star SEP is not available for us to use because we don’t have a Five-Star Plan in 2014. This is a concern for those of us that help with insurance. We like to offer opportunities to everyone to change their insurance. We have other SEPs that we can use, but not everyone falls into those circumstances.

Today I will focus on EPIC coverage and how that could help. EPIC is a New York State Pharmacy Assistance Program that provides very good prescription drug coverage to those who qualify. EPIC stands for Elderly Pharmaceutical Insurance Coverage. EPIC requires that you be 65 or older and a resident of New York state. The income guidelines require that a single person make less than $35,000 annually, a married couple make less than $50,000. If you think you qualify for EPIC, please call their Help-Line at 1-800-332-3742. Their customer service will answer your questions and send you an enrollment form. You can also get EPIC applications at your local pharmacy or New York State Office For the Aging office locations. I have them in my office as well.

EPIC has no set enrollment period. It allows open enrollment all the time. That means that if you want to apply, you can apply anytime as along you meet the previously described criteria. EPIC uses your income figures from last year. Those figures can be obtained from your tax return, if you file; if you don’t file, use your 1099 tax documents. You still receive these, even if you are not required to file taxes. You must also include your net Social Security income, which is not always taxable. I encourage all seniors to review their income every year to see if they qualify for EPIC – if not already covered by EPIC.

EPIC will always be secondary to your Part D insurance coverage. If you have a retiree plan or VA coverage, EPIC will not help you pay for prescriptions. EPIC will only be secondary to Medicare Part D plans.

Another benefit to EPIC is that it may also help you to pay for that Medicare Part D coverage. If your income is up to $23,000 as a single person or up to $29,000 as a married couple and enrolled in EPIC, EPIC will pay for the Medicare Part D plan up to the monthly premium of $37.23. If your monthly Medicare Part D premium is more than that, you will only pay the difference. If your premium for Part D is less than $37.23 EPIC will pay the entire Part D plan premium. For a married couple this will hold true for both of you.

EPIC also has an additional benefit. This additional benefit may be more useful to you than any other benefit EPIC offers. If you are enrolled in EPIC, it gives you a Special Enrollment Period (SEP) each year. This means that every year you have EPIC you have an additional one time opportunity to switch your prescription drug coverage from one product to another. This can be used at any time during the year, but only once each year.

For individuals in your situation, this gives you an opportunity to switch your insurance if you decide to. You can always evaluate whether or not switching your insurance makes sense. So if you missed the Dec. 7 deadline, you can use your EPIC SEP in December to switch plans and begin Jan. 1, or wait until after January to switch anytime you want during the year if necessary.

In counseling individuals with regard to their insurance, I have many times advised joining EPIC, not because an individual needs the additional drug coverage that badly, but because it gives them this SEP which we can use to make an advantageous insurance change.

If you don’t qualify for EPIC, you may have another Special Enrollment Period (SEP) available to you. There are 16 Special Enrollment Periods available to individuals during the year.

I will be covering these in an article early in 2014. The other 15 SEPs maybe useful to you and your situation as well.